Form Library – City of Roswell

Form Library

Below you’ll find links to information and forms, which you can view or download and print.

If you prefer talking with a HealthEZ representative, call 855-520-4324

Medical Benefit Information

City of Roswell Benefits Guide	Provides information on your medical, dental, vision, life insurance, and disability insurance benefits.
Medical Traditional Plan SBC	The Summary of Benefits and Coverage provides simple and consistent information about your $2,800 HSA Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Medical $2,000 HSA Plan SBC	The Summary of Benefits and Coverage provides simple and consistent information about your $2,800 HSA Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Medical $2,800 HSA Plan SBC	The Summary of Benefits and Coverage provides simple and consistent information about your $2,800 HSA Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Medical Value Based HSA Plan SBC	The Summary of Benefits and Coverage provides simple and consistent information about your $2,800 HSA Medical Plan, covered benefits, coverage limitations, cost sharing provisions, and exceptions.
Summary Plan Description (SPD)	Provides information on how the medical plan operates, when employees are eligible for benefits, how benefits are paid, and much more.
Value Based Plan Guide	Important information on how to access care and understanding your ID card.
Facility Request Form	Submit a completed form when you would like HealthEZ to reach out to your provider and answer any questions they may have regarding your plan.
Summary Plan Description	Provides detailed information about your medical benefits.
Marketplace Notice	Explains options for purchasing health coverage through the Insurance Marketplace.

Claim Reimbursement Forms

Medical Expense Reimbursement Form	Fill out the Medical Expense Reimbursement Form and submit to HealthEZ when you have paid out of pocket for medical expenses.
Prescription Reimbursement Form	Fill out the Prescription Reimbursement Form and submit to your Pharmacy Benefit Manager (PBM) when you have paid out of pocket for prescription expenses. This form can also be used for Covid-19 OTC reimbursement requests.

HealthEZ Resources

How To Read Your Statements	Provides a detailed breakdown of your statements to help you understand what you are viewing & how claims were processed.
Online Account Instructions	Provides information on how to create your online HealthEZ account.
Our Benefit Partners	Provides information on the City of Roswell’s benefits partners: HealthEZ, Cigna, and the CORE Wellness Center.
EZSPD©	An EZ to understand, short version of your Legal SPD.
How to find your EOB Statements?	Please refer to the PDF document for instructions on how to log in and access your statements through the app or your computer.

Pharmacy Services

Medicare Part D Notice	This notice has information about your current prescription drug coverage and about your options under Medicare’s prescription drug coverage.

Machine Readable File

Machine Readable File – Cigna Network	Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice. PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Machine Readable File - PHCS Practitioner and Ancillary Only Network	Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice. PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.
Machine Readable File - Out of Network	Machine Readable Files, published in accordance with the Transparency in Coverage final rule. The information contained in the files is accurate as of the “Last Updated” date and is subject to change at any time and without notice. PLEASE NOTE: Due to the amount of information contained in these files, some may be as large as one Terabyte (TB) in size. Please ensure you have the required memory capacity, hardware, and software capabilities before attempting to download. The Machine Readable Files are formatted to allow researchers, regulators, and application developers to more easily access and analyze data.

Preventative Wellness Services

Preventative Wellness Services	Provides information on your common preventative wellness services.

Important Notices

Precertification List	Procedures that commonly require precertification
Your Rights and Protections Against Surprise Medical Bills	When you get emergency care or get treated by an out-of-network provider at an in-network hospital or ambulatory surgical center, you are protected from surprise billing or balance billing.
Notice of Electronic Disclosure	Notice of Electronic Disclosure of Employee Benefit Notices, Summary Plan Description and Plan Amendments
Paper Employee Notices	Acknowledgement of Paper Employee Benefit Notices
Children's Health Insurance Program (CHIP) Notice	Explains how your eligibility for Medicaid or CHIP may qualify you for premium assistance to pay for your employer's health coverage
COBRA Notice	Explains your right to continue health benefits, if you were to lose them through your group health plan.
Health Insurance Portability and Accountability Act of 1996 (HIPAA) Notice	Explains how personal health information about you may be used and disclosed.
Newborn Act Notice	Explains how important protections for your members and their newborn children.
Special Enrollment Notice	Explains your right to enroll in your group health plan, if you lose your "other" health coverage.
The Genetic Information Nondiscrimination Act (GINA) Booklet	Explains how discrimination on genetic information is prohibited in group health plan coverage
Women's Health and Cancer Rights Act of 1998	Explains important protections for those who choose to have breast reconstruction, in connection with a mastectomy.
HealthEZ Privacy Policy	A summary of key provisions of our Privacy Notice.